1. Technical Field
The present invention relates to prescription benefits, and more particularly to an apparatus and method for creating, modifying, and maintaining formularies that define prescription drugs and treatments supported by prescription benefit programs.
2. Description of the Related Art
Employers often provide employees with various benefits upon commencing their employment. These benefits typically include a package which covers healthcare and prescription drugs (or products). The healthcare package is generally provided through a healthcare provider. The specific coverage offered to an employee can depend on several factors, including the particular coverage program negotiated by the employer. For example, the benefits available can be different depending on the medical coverage desired, the prescription medication available, etc. Furthermore, the specific benefits requested will directly effect the coverage cost.
Regardless of the coverage, the healthcare provider will place certain restrictions and/or limitations on the prescription medication, or drugs, an employee can take. These restrictions determine whether the healthcare provider will cover the cost of a prescription in full or in part. For example, the healthcare provider may deny coverage for a name brand prescription product, while defining different levels of copay for various generic or substitute products. Healthcare providers use formularies to define the prescriptions products and treatments that a particular plan will cover. A formulary is a comprehensive list of pharmaceutical products that can be used as preferred products within a prescription plan offered to an employer. The formulary can include both brand name and generic products. The specific products in a formulary are selected, in part, based on safety, efficacy, and cost. Formularies can also be used, in part, to define the hierarchies that determine the various levels of copay that the healthcare provider will cover.
Design of a new formulary typically requires review of hundreds and sometimes thousands of individual prescription (e.g., pharmaceutical) products based on assigned National Drug Code (NDC) identifiers. As used herein, the term pharmaceutical product refers to any product, treatment, and/or therapy that is assigned a National Drug Code identifier. Each prescription coverage plan offered by the healthcare provider can include hundreds and sometimes thousands of different products. The healthcare provider must also define rules that determine how newly approved products will be treated under a particular formulary. As can be seen, the design and implementation of formularies for prescription coverage programs can involve numerous and complex decision-making steps resulting in the consumption of a great deal of time. Adding to this complication is the fact that a healthcare provider has many clients, each of whom may request different prescription coverage plans.
Various difficulties have been encountered in creating and modifying formularies. One process, originally practiced by the current assignee, has involved extensive dialogue and/or interaction with healthcare providers for creating and modifying the formulary for each prescription coverage plan. This process has proved very time consuming and complex due, at least in part, to the large number of products under government regulation. Specifically, there are over 140,000 products assigned NDC identifiers that may require individual review by the healthcare provider.
Traditionally, the healthcare provider would meet with a clinical account executive (CAE) to discuss the general requirements of the prescription coverage plan. The essence of the discussion, or the discussion itself, would be captured and converted to a computer document. The document would then be reviewed by formulary operations personnel, or programmers, to determine if it contains sufficient information to create the formulary. The programmers compare information contained in the document with clinical information contained in an Integrated Drug File (IDF) to determine which name brand products, generics, etc. should be included in the formulary for the prescription coverage plan. This results in the creation of a temporary formulary that is repeatedly exchanged between CAEs and programmers for review and modification.
Once the CAE is satisfied with the temporary formulary, it must be reviewed with the healthcare provider. This process again must be repeated until the healthcare provider is satisfied. The dialogue between different parties can often extend for weeks and months to create and/or modify the formulary for a single prescription coverage plan. Additionally, the information must be presented on paper, or other tangible form, for review and modification by the healthcare provider. For example, the NDC identifiers of all products in the prescription coverage plan must be reviewed and marked for inclusion or exclusion in the formulary. Thus, data accuracy can often become an issue.
Maintaining and modifying formularies to accommodate client needs can often prove to be a challenging task requiring many months to complete. In addition, inherent error potentials cannot be eliminated. Furthermore, these errors will often translate directly to increased costs as well as exposure to liability for the healthcare provider. Over time, these costs can quickly accumulate, particularly when formularies require an extended period of time to create.
Accordingly, there exists a need for a system capable of quickly and efficiently creating prescription formularies.
There also exists a need for a system which minimizes the amount of time required to create a formulary while providing access to all products assigned on NDC identifier.
There exists a further need for a system which allows healthcare providers an ability to create formulary templates that can be quickly modified to suit client needs.
There exists a still further need for a system capable of automatically incorporating newly approved products into an existing formulary.